Celebrating 25 Years of Practical Bioethics

Rosemary Flanigan
May 11, 2009

We had a gala week last week celebrating our 25th anniversary of the Center for Practical Bioethics.Former Senator Jack Danforth gave the talk (he had involved Myra Christopher in the discussion leading up to the Patient Self-Determination Act of 1990) and I shall comment on that when I have read his talk.

But the next morning we heard from four participants of the meeting of directors of ethics programs that was being held in KC, and we had a good crowd for that, too. Eric Kodish from the Cleveland Clinic gave the arguments pro and con about using babies in research that does not directly benefit them. (It was an excellent “doing of ethics” with the arguments clearly made.)

David Magnus from Stanford talked about the ethical issues related to organ donation after cardiac arrest. He set up the problems well: when is dead “dead”??? How resolve conflicts between physicians and institutions?? What if measures to preserve the organs do not benefit the patient? He did an excellent job “placing” the argument.

Alan Meisel from the University of Pittsburg asked if physician-aid-in-dying is inevitable? in error? or both? And pointed out the incremental advances being made by those supporters of the movement. He said we have to do a better job of distinguishing active from passive euthanasia—and I was surprised because I think neither is helpful in this discussion. He had some excellent arguments against the movement.

Finally, Glenn McGee with the American Journal of Bioethics talked on autism (he has an autistic son) and how the media attention on the subject has radically altered parents’ relationships to their autistic children. (You can tell I couldn’t hear him very well—maybe one of our staff or attendees will do a better job here.)

So after all that heady stuff, we’re back to normal in mid-May.

Links:

Balancing Faith and Politics, John C. Danforth, The Bioethics Channel, May 8, 8 minutes 39 seconds

Lecture, John C. Danforth, May 7 (pdf document)

Health Care Rationing with Universal Coverage and in Time of Pandemics, Up to Date, KCUR Radio, May 8

Presumed Consent for Organ Donation? An Unlikely Fix

Tarris Rosell, PhD, DMin
January 23, 2009

Would changing the way we ask for organ donations—i.e., by not asking—make a dent in the transplant waiting list? “Presumed consent” is policy in a few nations less individualistic than our own. Has it helped? Our British cousins want to know.

The United Kingdom may be considering a change from their current opt-in system of organ donation after death, to one that would presume donor consent unless the donor or next of kin specifically were to opt-out prior to surgical recovery of usable body parts.

Science Daily reports optimistically on a systematic review of 26 studies and opinion surveys currently posted on the website of the British Medical Journal.

The review, compiled by the Centre for Reviews and Dissemination at the University of York in the U.K., suggests a correlation between presumed consent policies and higher donation rates. However, the report carries significant caveats to these findings, as well.

We keep looking for ways to balance supply with demand in the currently lopsided system of donate and wait. Some donate while many nonetheless continue to wait.

“First person consent” laws passed in most states of the United States have done little to change the negative ratio. “Presumed request” protocols—a way of asking potential donors that presumes a favorable response—reportedly have yielded some success, but not without a turn-off factor due to an unfortunate association with high pressure marketing techniques.

Living donation of kidneys and other paired organs increased significantly over the past two decades, but tapered off more recently. Living donation too is not without ethical complications and statistical limitations relative to the shortage of donor organs.

LifeSharers (www.LifeSharers.org) innovatively and controversially aims to incentivize cadaveric donation by means of what their local business journal called an “organ club.” “Organs for organ donors,” is the LifeSharers tagline.

But after seven years and much national publicity, there are only about 12,000 members and a net gain of zero donors and recipients (http://www.lifesharers.org/faq.asp).

I think presumed consent laws also are no panacea to a growing and complex problem.

In any case, the U.K. is not the U.S.A. Even if the British buy into an opt-out system for organ donation, it seems unlikely that Americans will follow suit any time soon.

We retain a strong individualism that places less value on solidarity than on autonomy. It is not so everywhere, of course, and might not be descriptive of this society when a seemingly more communitarian Boomer Babies generation takes the reigns of power within the next 20 years or so.

By then, we hopefully will have discovered radically new clinical responses to end-stage organ disease, something less morally messy perhaps than organ donation and transplantation.

If not, will either the U.S. or the U.K. have presumed consent laws in place? Were this to happen, it is possible that donation rates could rise a bit, and that a few more lives could be improved and extended by transplant medicine. And if one of the few is your life or mine or that of our loved one, it surely will seem worth it.

Yet, it is not possible to meet the rising demand for transplantable organs by means of presumed consent, whether here or across the pond. The need is simply too great, and growing exponentially just for renal organs alone. The cadaveric donor pool is too small, no matter what laws are passed in the near or distant future.

Might there be a more fitting response to this shared dilemma?

What do you think? To view and share comments click here.

Link: Redefining death: A new ethical dilemma, American Medical News, January 19

Can Anything Good Come of the Navarro Fiasco?

Terry Rosell
December 23, 2008

A transplant surgeon has been acquitted of criminal wrongdoing in the dying of Ruben Navarro http://www.latimes.com/features/health/la-me-transplant19-2008dec19,0,2830878.story. With limited knowledge of what went on in the operating room and the courtroom, I assume this is a good outcome.

But I think the jury is still out on public opinion regarding donation of body parts after cardiac death, and on what should happen next.

Dr. Hootan Roozrokh was accused, and is found not guilty, of dependent adult abuse. He had flown in with a team from San Francisco to procure organs upon the death of Mr. Navarro at the regional medical center in San Luis Obispo.

Organ recovery usually takes place after brain death. This 25 year old comatose patient was not brain dead, and was expected to die the old fashioned way. He had suffered cardiac arrest once already, and his family had consented to organ donation at such time as his heart stopped permanently.

But things didn’t proceed as they should. A prosecuting attorney claimed, unconvincingly, that Dr Roozrokh hastened the prospective donor’s death by ordering relatively large doses of pain and anti-anxiety medications for a patient who was not dying quickly enough. Defense convinced the jury that whatever occurred in that operating room, it wasn’t criminal.

Indeed, it may well have been compassionate care of a patient who was suffering needlessly and in a prolonged manner.

What all can agree on is that, whatever happened in San Luis Obispo, it resulted in little good beyond that of the defense attorney’s claims. Yes, the patient’s suffering was ended. However, the bereaved family experienced a grief complicated by suspicions of medical abuse and a long court battle.

The young surgeon experienced a disruption of vocation from which he may never recover fully. Other well intended clinical caregivers surely were traumatized by testimony or depositions, by the scrutiny of law and media. Organ procurement and hospital institutions have expended scarce resources that might have gone to healing rather than defending.

The American public is left wondering who to trust and whether organ donation is a risky endeavor. And in the Navarro case, no organs ultimately were recovered anyway.

If there is anything good yet to come of this tragedy, it will be seen in the delineation of clearer policies and procedures for recovery of organs and tissue after cardiac death—with sanctions for violation, whether intentional or unintentional. What we hope will not occur is clinical resistance to or additional restrictions on administration of pain and anti-anxiety medications for patients who are actively dying.

That would be tragedy upon tragedy. Clinicians and policy wogs need to focus attention elsewhere.

In reference to recovery of organs after cardiac death, Cleveland transplant surgeon Dr. John Fung accurately noted that the Navarro case “certainly highlighted the potential of extreme problems that could occur without having the proper policies and procedures in place.” (http://www.latimes.com/features/health/la-me-transplant19-2008dec19,0,2830878.story).

The jury concurred with the need for “well defined ethical standards.” Now it is mostly up to the United Network for Organ Sharing (UNOS) and its Department of Health and Human Services contractor to take appropriate actions with sufficient communication such that this fiasco is less apt to be repeated elsewhere or ever again.

I hope they are doing so.

Link: Transplant surgeon acquitted in case involving potential organ donor's death, Los Angeles Times, December 19

What do you think? Please view and share comments.

OPOs, stop and think!

Tarris Rosell, PhD, DMin
Program Associate
October 23, 2008

How dead does a “cadaveric” organ donor need to be before the heart is removed for transplantation? Or ought death be the necessary precondition for doing so?

Even asking these questions may seem crass and insensitive to those families who have given the “gift of life.” It also is ringing alarms for some Roman Catholic pro-life moralists, according to a recent article in The Economist (http://www.economist.com/science/displaystory.cfm?story_id=12332939).

These are matters more commonly discussed in medical and bioethics journals. Yet organ procurement policies do indeed have something to do with economics, despite U.S. laws forbidding commerce in transplantable organs.

Donors or their families receive no compensation, or ought not, we say; but organ procurement organizations (OPOs) pay decent executive salaries and transplant clinicians may receive even better ones. Transplantation is expensive medicine, with much money legitimately trading hands.

Another interest to economists is the law of supply and demand, which is a perpetual problem for transplanters. Organ supply is woefully short of patients’ demand.

What to do? In a recent New England Journal of Medicine article (http://content.nejm.org/cgi/content/full/359/7/674?query=TOC), Dr. Robert Truog has suggested that we increase organ supply by dispensing with the “dead donor rule.”

(See Center blog for 8/20/08: http://practicalbioethics.blogspot.com/2008_08_17_archive.html)

He argues that we should procure vital organs like the heart and lungs before either cardiac or brainstem death so as to minimize cell death in transplantable organs and thereby maximize transplant success.

Criteria for doing so, says Truog, would be prior signed consent of the donor and a subsequent situation of irreversible severe brain damage with do-not-resuscitate orders.

This worries many of us, notes The Economist, and particularly so some Catholic scholars who will gather at the Vatican in November for a conference on organ donation. “O death, when is thy sting?” quips the journalist. “OPOs, stop and think!” may be the more somber religious pro-life response to Truog and his proposal.

I too think this is a matter not to be ignored in an era of short supply and high demand for human body parts. Clearly, moral boundaries and clinical guidelines are shifting. Perhaps that is not a bad thing. But more thoughtful dialogue is needed, both by economists and ethicists, religious scholars and organ procurers, those who transplant body parts and those who would receive them.

Demand alone is insufficient moral justification for increasing supply by any means imaginable. On this we all agree. Could we have imagined, even a short time ago, that a serious proposal would be offered for recovering vital organs before declaration of donor death?

Sold To The Lady With the Alligator Purse!!!

Myra Christopher, President & CEO
Center for Practical Bioethics
mchristopher@practicalbioethics.org

July 11, 2008

In June, the American Medical Association House of Delegates voted to attempt to change the federal law which prohibits the buying and selling of organs in order to study using financial incentives to increase cadaveric organ donations. This idea has been discussed for at least fifteen years, and the house approved a similar plan six years ago.

But, the 1984 National Organ Transplant Act makes even a pilot study illegal.

When there are nearly 100,000 people currently on the waiting list for organs, it is easy to understand why well-intended people are eager to test this notion.

However, I would remind readers that in 1993 when the Ethics Committee of United Network for Organ Sharing considered this concept, they concluded "only if and when financial incentives for organ donation are widely accepted as different from purchasing of organs, can this alternative be proposed as preferable to the current system of altruistic organ donation."

To my knowledge data does not exist to indicate that this has happened. What does exist is evidence of increasing healthcare disparities between "haves" and "have nots" in our society and distrust of the healthcare system by those who have been traditionally underserved and marginalized because of color, ethnicity, or socio-economic status.

Organ donation in this country rests on two pillars: altruism of donors and almost absolute trust in transplant teams. Although motivated by "good" reasons, I believe that financial incentives could undermine our current system and that the 1984 law has served us well.

What do you think? Share and view your comments by clicking here.

Links:

AMA delegates seek to change law on organ donor incentives, American Medical News, July 7

Black market in organs uncovered, BBC News, July 9